Changes in HIV prevention programme outcomes among key populations in Kenya: Data from periodic surveys

Assessing Outcomes in HIV Prevention and Treatment Programs With Female Sex Workers and Men Who Have Sex With Men: Expanded Polling Booth Survey Protocol

BACKGROUND

Assessing HIV outcomes in key population prevention programs is a crucial component of the program cycle, as it facilitates improved planning and monitoring of anticipated results. The Joint United Nations Programme on HIV and AIDS recommends using simple, rapid methods to routinely measure granular and differentiated program outcomes for key populations. Following a program science approach, Partners for Health and Development in Africa, in partnership with the Nairobi County Government and the University of Manitoba, aims to conduct an outcome assessment using a novel, expanded polling booth survey (ePBS) method with female sex workers and men who have sex with men in Nairobi County, Kenya.

OBJECTIVE

This study aims to (1) estimate the incidence and prevalence of HIV; (2) assess biomedical, behavioral, and structural outcomes; and (3) understand barriers contributing to gaps in access and use of available prevention and treatment services among female sex workers and men who have sex with men in Nairobi.

METHODS

The novel ePBS approach employs complementary data collection methods, expanding upon the traditional polling booth survey (PBS) method by incorporating additional quantitative, qualitative, and biological data collection components and an improved sampling methodology. Quantitative methods will include (1) PBS, a group interview method in which individuals provide responses through a ballot box in an unlinked and anonymous way, and (2) a behavioral and biological survey (BBS), including a face-to-face individual interview and collection of linked biological samples. Qualitative methods will include focus group discussions. The ePBS study uses a 2-stage, population- and location-based random sampling approach involving the random selection of locations from which random participants are selected at a predetermined time on a randomly selected day. PBS data will be analyzed at the group level, and BBS data will be analyzed at an individual level. Qualitative data will be analyzed thematically.

RESULTS

Data were collected from April to May 2023. The study has enrolled 759 female sex workers (response rate: 759/769, 98.6%) and 398 men who have sex with men (response rate: 398/420, 94.7%). Data cleaning and analyses are ongoing, with a focus on assessing gaps in program coverage and inequities in program outcomes.

CONCLUSIONS

The study will generate valuable HIV outcome data to inform program improvement and policy development for Nairobi County's key population HIV prevention program. This study served as a pilot for the novel ePBS method, which combines PBS, BBS, and focus group discussions to enhance its programmatic utility. The ePBS method holds the potential to fill an acknowledged gap for a rapid, low-cost, and simple method to routinely measure HIV outcomes within programs and inform incremental program improvements through embedded learning processes.

Virologic Nonsuppression and HIV Drug Resistance Among People Who Inject Drugs and Their Sexual and Injecting Partners in Kenya

We evaluated the prevalence and correlates of HIV viral nonsuppression and HIV drug resistance (HIV-DR) in a cohort of people who inject drugs living with HIV (PWID-LH) and their sexual and injecting partners living with HIV in Kenya. HIV-DR testing was performed on participants with viral nonsuppression. Of 859 PWID-LH and their partners, 623 (72.5%) were on antiretroviral therapy (ART) ≥4 months and 148/623 (23.8%) were not virally suppressed. Viral nonsuppression was more common among younger participants and those on ART for a shorter duration. Among 122/148 (82.4%) successfully sequenced samples, 55 (45.1%) had detectable major HIV-DR mutations, mainly to non-nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI and NRTI). High levels of HIV-DR among those with viral nonsuppression suggests need for viral load monitoring, adherence counseling, and timely switching to alternate ART regimens in this key population.

The epidemiology of HIV infection among female sex workers in Nairobi, Kenya: A structural determinants and life-course perspective

High HIV prevalence among female sex workers (FSWs) is heavily influenced by structural determinants (e.g. criminalisation of sex work; violence) and significant life events (e.g. orphanhood, teenage pregnancy). This study aims to understand the epidemiology of HIV among FSWs in Nairobi, Kenya using a structural determinants and life-course perspective. Baseline cross-sectional survey data were collected June-December 2019 for the Maisha Fiti study with 1003 FSWs (aged 18-45 years). Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression with a hierarchical modelling approach. HIV prevalence was 28.0%, and increased with age (<25 years 5.7%, 25-34 years 19.0%, ≥35 years 40.6%). In adjusted analyses, HIV seroprevalence was associated with childhood and adolescence including violence from militia or soldiers (AOR = 1.60; 95%CI:1.00-2.53), young age at sexual debut (≤15 years old vs. ≥18 years AOR = 0.57; 95%CI:0.39-0.84) and teenage pregnancy (AOR = 1.37; 95%CI:1.00-1.88). For adulthood the factors included lower SES score (lowest vs. highest tertile AOR = 0.63; 95%CI:0.40-0.98); reduced housing insecurity (AOR = 0.52; 95%CI:0.54-0.79); lower alcohol/drug use score (AOR = 0.44; 95%CI:0.31-0.61); and a longer duration of selling sex (0-5 years vs. ≥11 years AOR = 2.35; 95%CI:1.44-3.82). Among HIV-negative FSWs, prevalence of HIV risk factors was high (recent hunger 32.3%; internalised 67.7% and experienced 66.0% sex work stigma; recent police arrest 30.1%; recent physical or sexual violence 65.6%, condomless last sex intimate partner 71.1%; harmful alcohol or substance use 49.1%). Only 24.6% of HIV-negative FSWs reported taking PrEP. Taken together, adverse events in childhood and adolescence were associated with increased odds of living with HIV, and were more strongly associated with HIV serostatus than adulthood structural or behavioural risk factors. HIV-negative FSWs remain at high risk of HIV acquisition. This study highlights the importance of addressing adverse events throughout the life course to reduce HIV risk, and the need to continue multi-level HIV prevention and treatment efforts.

Programme science: a route to effective coverage and population-level impact for HIV and sexually transmitted infection prevention

Improvements in context-specific programming are essential to address HIV and other sexually transmitted and blood-borne infection epidemics globally. A programme science approach emphasises the need for context-specific evidence and knowledge, generated on an ongoing basis, to inform timely and appropriate programmatic decisions. We aim to accelerate and improve the use of embedded research, inquiry, and learning to optimise population-level impact of public health programmes and to introduce an effective programme coverage framework as one tool to facilitate this goal. The framework was developed in partnership with public health experts in HIV and sexually transmitted and blood-borne infections through several workshops and meetings. The framework is a practice-based tool that centres on the use of data from iterative cycles of programme-embedded research and learning, as well as routine programme monitoring, to refine the strategy and implementation of a programme. This programme science approach aims to reduce programme coverage gaps, to optimise impact at the population level, and to achieve effective coverage. This framework should facilitate the generation of programme-embedded research and learning agendas to inform resource allocation, optimise population-level impact, and achieve equitable and effective programme coverage.

Syndemic of factors that shape the early lives of women who enter into sex work: a qualitative methods study from Nairobi, Kenya

OBJECTIVE

To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya.

DESIGN

Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi.

PARTICIPANTS AND MEASURES

FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural-biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management.

RESULTS

48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency.

CONCLUSIONS

This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

Oral Pre-Exposure Prophylaxis (PrEP) Awareness and Acceptability Among Persons who Inject Drugs (PWID) in Kenya: A Qualitative Investigation

Background

People who inject drugs (PWID) are disproportionately affected by HIV despite the availability of multiple efficacious biomedical prevention interventions including oral pre-exposure prophylaxis (PrEP). Little is known about the knowledge, acceptability, and uptake of oral PrEP among this population in Kenya. To inform the development of oral PrEP uptake optimization interventions for PWID in Kenya, we conducted a qualitative assessment to establish oral PrEP awareness and willingness to take PrEP by this group in Nairobi City.

Methodology

Guided by the Capability, Opportunity, Motivation, and Behaviour (COM-B) model of health behavior change, we conducted 8 focus group discussions (FGDs) among randomly constituted samples of PWID in four harm reduction drop-in centers (DICs) in Nairobi in January 2022. The domains explored were: perceived risks (behaviour), oral PrEP awareness and knowledge (capability), motivation to use oral PrEP (behaviour), and perceptions on community uptake (motivation and opportunity). Completed FGD transcripts were uploaded to Atlas.ti version 9 and thematic analysis was conducted through an iterative process of review and discussion by two coders.

Findings

There was a low level of oral PrEP awareness with only 4 of the 46 PWID having heard of PrEP; only 3 out of 46 participants had ever used oral PrEP and 2 out of 3 were no longer using it, indicating a low capacity to make decisions on oral PrEP. Most study participants were aware of the risk posed by unsafe drug injection and expressed willingness to take oral PrEP. Nearly all participants demonstrated low understanding of the role oral PrEP plays in complementing condoms in HIV prevention, presenting an opportunity for awareness creation. While the PWID were eager to learn more about oral PrEP, they favored DICs as places where they would like to obtain information and oral PrEP if they chose to use it, identifying an opportunity for oral PrEP programming interventions.

Conclusion

Creation of oral PrEP awareness among PWID in Kenya is likely to improve uptake since the PWID are receptive. Oral PrEP should be offered as part of combination prevention approaches, and effective messaging through DICs, integrated outreaches, and social networks are recommended to mitigate displacement of other prevention and harm reduction practices by this population.

Trial Registration

ClinicalTrials.gov Protocol Record STUDY0001370.

Occupational roles and risks of community-embedded peer educators providing HIV, hepatitis C and harm reduction services to persons who inject drugs in Nairobi, Kenya

BACKGROUND

In Kenya, harm reduction organizations have adopted evidence-based peer educator (PE) programs, where former people who inject drugs (PWID) serve as community health liaisons to engage PWID in HIV, HCV and harm reduction services. While PEs play an integral role in healthcare delivery, little data exists on their roles, risks and experiences working with PWID, which may be used to inform local harm reduction policy.

METHODS

PE's from two harm reduction sites in Nairobi were randomly and purposively selected to participate in semi-structured in-depth interviews. Thematic analysis was conducted to characterize the expected versus actual roles that PEs employ while serving PWID, personal motivation and/or challenges and occupational health risks. Data was analyzed using Atlas.ti software.

RESULTS

Twenty PEs participated in the study. On average, PEs were 37 years of age, with 3 years of service. Female representation was 30%. Expected responsibilities included locating clients, establishing rapport, educating and escorting clients to addiction care facilities. Additional roles included attending to clients outside of work hours, escorting clients to medical appointments and facilitating patient-provider discussions. Occupational health risks included harassment by police and drug dealers, needle sticks, and close proximity to drug use environments that could prompt drug relapse. Despite these challenges and risks, PEs are motivated by their personal experiences of overcoming addiction with help from harm reduction programs.

CONCLUSIONS/RECOMMENDATIONS

PEs play a vital role in HIV, HCV and harm reduction service delivery in Kenya, often exceeding their job descriptions by offering additional support to PWID. Recommendations include (1) advocating for PEs to provide patient navigation services, (2) promoting the use of post-exposure prophylaxis (PEP), (3) providing occupational mental health services to prevent drug relapse, and (4) collaborating with law enforcement to address harassment, with the ultimate goal of reducing HIV and HCV incidence among PWID.

HIV prevention programme with young women who sell sex in Mombasa, Kenya: learnings for scale-up

Introduction

In 2018, the National AIDS and sexually transmitted infection (STI) Control Programme developed a national guidelines to facilitate the inclusion of young women who sell sex (YWSS) in the HIV prevention response in Kenya. Following that, a 1‐year pilot intervention, where a package of structural, behavioural and biomedical services was provided to 1376 cisgender YWSS to address their HIV‐related risk and vulnerability, was implemented.

Methods

Through a mixed‐methods, pre/post study design, we assessed the effectiveness of the pilot, and elucidated implementation lessons learnt. The three data sources used included: (1) monthly routine programme monitoring data collected between October 2019 and September 2020 to assess the reach and coverage; (2) two polling booth surveys, conducted before and after implementation, to determine the effectiveness; and (3) focus group discussions and key informant interviews conducted before and after intervention to assess the feasibility of the intervention. Descriptive analysis was performed to produce proportions and comparative statistics.

Results

During the intervention, 1376 YWSS were registered in the programme, 28% were below 19 years of age and 88% of the registered YWSS were active in the last month of intervention. In the survey, respondents reported increases in HIV‐related knowledge (61.7% vs. 90%, p <0.001), ever usage of pre‐exposure prophylaxis (8.5% vs. 32.2%, p < 0.001); current usage of pre‐exposure prophylaxis (5.3% vs. 21.1%, p<0.002); ever testing for HIV (87.2% vs. 95.6%, p <0.04) and any clinic visit (35.1 vs. 61.1, p <0.001). However, increase in harassment by family (11.7% vs. 23.3%, p<0.04) and discrimination at educational institutions (5.3% vs. 14.4%, p<0.04) was also reported. In qualitative assessment, respondents reported early signs of success, and identified missed opportunities and made recommendations for scale‐up.

Conclusions

Our intervention successfully rolled out HIV prevention services for YWSS in Mombasa, Kenya, and demonstrated that programming for YWSS is feasible and can effectively be done through YWSS peer‐led combination prevention approaches. However, while reported uptake of treatment and prevention services increased, there was also an increase in reported harassment and discrimination requiring further attention. Lessons learnt from the pilot intervention can inform replication and scale‐up of such interventions in Kenya.

Unmet Need for Contraception Among Female Sex Workers Initiating Oral Pre-Exposure Prophylaxis for HIV Prevention During Kenya's National Scale-Up: Results From a Programmatic Surveillance Study

Background

Female sex workers (FSWs) experience a higher risk for both HIV acquisition and unwanted pregnancies compared to women in the general population. Pre-exposure prophylaxis (PrEP) for HIV prevention offers protection against HIV infection but has no contraceptive effect. We examined the determinants of unmet need for contraception among FSWs who initiated PrEP to inform programs and policies to optimize contraceptive services and avert unwanted pregnancy among this high-risk group.

Materials and Methods

A cross-sectional analysis was conducted on routine, de-identified client data from a large-scale PrEP service delivery project, from February 2017 to December 2019. Data were collected from FSWs during clinic visits using Ministry of Health approved tools. Records for all 17,456 FSWs initiated on PrEP from 79 health facilities in 10 counties across three geographic clusters with high and medium HIV incidence were examined for eligibility for the analysis. Unmet need for non-barrier contraception was defined as not being pregnant, not currently using the non-barrier contraceptive method, and not trying to conceive or intending to have a child in the near future. Univariate and multivariable regression analyses were conducted with selected variables to examine associations.

Results

In the 79 sites, eligible records from 17,063 FSWs who initiated PrEP were included. Two-thirds were under 30 years, and the majority were not married and had received PrEP at drop-in centers. Overall, the unmet need for non-barrier contraception was 52.6%, higher for those under 20 years of age (60.9%) and those served in public and private health facilities (67.4 and 83.2%, respectively) rather than drop-in centers (50.6%). Women from the Nairobi and Coast cluster regions reported a higher unmet need for contraception compared to those from the Lake region. All these associations were significant (p < 0.05) at the multivariate level.

Conclusions

The high unmet need for non-barrier contraception among FSWs initiating PrEP highlights the need for integrated delivery of contraception services within PrEP programs. Identifying groups with a high unmet need could lead to higher success in an integrated program. Two recommended approaches include training healthcare providers to deliver clear contraception messaging during PrEP initiation and making a range of contraceptives accessible within PrEP services for high-risk groups. Furthermore, accelerated research on multipurpose prevention technologies is necessary to reduce the burden on individuals using multiple prevention products concurrently.

Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance

Background

Female sex workers (FSW) and men having sex with men (MSM) in Kenya have high rates of HIV infection. Following a 2015 WHO recommendation, Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk. Concerns have been raised about PrEP users' potential changes in sexual behaviors such adopting condomless sex and multiple partners as a result of perceived reduction in HIV risk, a phenomenon known as risk compensation. Increased condomless sex may lead to unintended pregnancies and sexually transmitted infections and has been described in research contexts but not in the programmatic setting. This study looks at changes in condom use among FSW and MSM on PrEP through a national a scale-up program.

Methods

Routine program data collected between February 2017 and December 2019 were used to assess changes in condom use during the first three months of PrEP in 80 health facilities supported by a scale-up project, Jilinde. The primary outcome was self-reported condom use. Analyses were conducted separately for FSW and for MSM. Log-Binomial Regression with Generalized Estimating Equations was used to compare the incidence proportion (“risk”) of consistent condom use at the month 1, and month 3 visits relative to the initiation visit.

Results

At initiation, 69% of FSW and 65% of MSM reported consistent condom use. At month 3, this rose to 87% for FSW and 91% for MSM. MSM were 24% more likely to report consistent condom use at month 1 (Relative Risk [RR], 1.24, 95% Confidence Interval [CI], 1.18–1.30) and 40% more likely at month 3 (RR, 1.40, 95% CI, 1.33–1.47) compared to at initiation. FSW were 15% more likely to report consistent condom use at the month one visit (RR, 1.15, 95% CI, 1.13–1.17) and 27% more likely to report condom use on the month 3 visit (RR 1.27, 95% CI, 1.24–1.29).

Conclusion

Condom use increased substantially among both FSW and MSM. This may be because oral PrEP was provided as part of a combination prevention strategy that included counseling and condoms but could also be due to the low retention rates among those who initiated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12639-6.

An intensive model of care for hepatitis C virus screening and treatment with direct-acting antivirals in people who inject drugs in Nairobi, Kenya: a model-based cost-effectiveness analysis

BACKGROUND AND AIMS

Hepatitis C virus (HCV) treatment is essential for eliminating HCV in people who inject drugs (PWID), but has limited coverage in resource-limited settings. We measured the cost-effectiveness of a pilot HCV screening and treatment intervention using directly observed therapy among PWID attending harm reduction services in Nairobi, Kenya.

DESIGN

We utilized an existing model of HIV and HCV transmission among current and former PWID in Nairobi to estimate the cost-effectiveness of screening and treatment for HCV, including prevention benefits versus no screening and treatment. The cure rate of treatment and costs for screening and treatment were estimated from intervention data, while other model parameters were derived from literature. Cost-effectiveness was evaluated over a life-time horizon from the health-care provider's perspective. One-way and probabilistic sensitivity analyses were performed.

SETTING

Nairobi, Kenya.

POPULATION

PWID.

MEASUREMENTS

Treatment costs, incremental cost-effectiveness ratio (cost per disability-adjusted life year averted).

FINDINGS

The cost per disability-adjusted life-year averted for the intervention was $975, with 92.1% of the probabilistic sensitivity analyses simulations falling below the per capita gross domestic product for Kenya ($1509; commonly used as a suitable threshold for determining whether an intervention is cost-effective). However, the intervention was not cost-effective at the opportunity cost-based cost-effectiveness threshold of $647 per disability-adjusted life-year averted. Sensitivity analyses showed that the intervention could provide more value for money by including modelled estimates for HCV disease care costs, assuming lower drug prices ($75 instead of $728 per course) and excluding directly-observed therapy costs.

CONCLUSIONS

The current strategy of screening and treatment for hepatitis C virus (HCV) among people who inject drugs in Nairobi is likely to be highly cost-effective with currently available cheaper drug prices, if directly-observed therapy is not used and HCV disease care costs are accounted for.

Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey

BACKGROUND

A Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic.

METHODS

A cross-sectional study design was adopted in which a set of initial subjects referred to as 'seeds' were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO's) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides.

RESULTS

A total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20-29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11-19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20-24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions.

CONCLUSIONS

Compared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20-29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya

INTRODUCTION

Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya's challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade.

DISCUSSION

The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non-regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP-led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio-behavioural survey data; inadequate scale-up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma.

CONCLUSIONS

To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale-up quality programmes for KP who are underserved in the HIV response.

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya

BACKGROUND

We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots.

METHODS

We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models.

RESULTS

N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)].

CONCLUSION

Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

Low engagement in HIV services and progress through the treatment cascade among key populations living with HIV in Mozambique: alarming gaps in knowledge of status

Background

Mozambique has a generalized HIV epidemic of 13.5% among the general population. Early modeling exercises in Mozambique estimate that key populations (KP), defined as men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID), along with their partners account for about one third of all new infections. There is limited data describing the engagement of KP living with HIV in testing, care and treatment services.

Methods

We conducted a secondary data analysis of HIV-positive participants in the first Bio-behavioral Surveillance (BBS) surveys in Mozambique conducted 2011–2014 in order to assess service uptake and progress though the HIV treatment cascade among MSM, FSW, and PWID. Unweighted pooled estimates were calculated for each key population group.

Results

Among HIV-positive MSM, 63.2% of participants had ever received an HIV test, 8.8% were aware of their status, 6.1% reported having been linked to care, while 3.5% initiated ART and were currently on treatment. Of the HIV-infected FSW participants, 76.5% reported a previous HIV test and 22.4% were previously aware of their status. Linkage to care was reported by 20.1%, while 12.7% reported having initiated ART and 11.8% reported being on treatment at the time of the survey. Among HIV-infected PWID participants, 79.9% had previously received an HIV test, 63.2% were aware of their HIV status, and 49.0% reported being linked to care for their HIV infection. ART initiation was reported by 42.7% of participants, while 29.4% were on ART at the time of the survey.

Conclusion

Among the three high risk populations in Mozambique, losses occurred throughout critical areas of service uptake with the most alarming breakpoint occurring at knowledge of HIV status. Special attention should be given to increasing HIV testing and linkage to ART treatment. Future surveys will provide the opportunity to monitor improvements across the cascade in line with global targets and should include viral load testing to guarantee a more complete picture of the treatment cascade.

HIV infections among female sex workers in Mombasa, Kenya: current prevalence and trends over 25 years

Over 20 years, interventions have targeted HIV among female sex workers (FSWs) in Kenya given their central role in new infections. To determine the effects of these interventions, we assessed the prevalence and correlates of HIV among a random sample of FSWs and modelled prevalence estimates from studies since 1993. FSWs aged 16-34 years were enrolled through multi-stage sampling. Regression models identified correlates of HIV infection. Generalised linear mixed modelling estimated temporal changes in prevalence between 1993 and 2016. 882 FSWs were enrolled. Prevalence rose from 3.6% among 16-20-year-olds to 31.6% among 31-34-year-old FSWs. Those aged 31 to 34 years had greater odds of HIV compared to those 16 to 20 years (AOR 14.2, 95% CI, 5.5-36.8). Infection was less prevalent among FSWs with tertiary education compared to those with primary or no education (AOR 0.23, 95% CI, 0.07-0.78). There was an overall 30% reduction in prevalence from 1993 to 2016 with an average annual decline of 3%. About one in ten FSWs in Mombasa are currently infected with HIV. Considering FSWs' central role in sustaining population-level infections, these initiatives require continued support, focusing on reducing transmission from older FSWs and those with less education.

Low program access despite high burden of sexual, structural, and reproductive health vulnerabilities among young women who sell sex in Mombasa, Kenya

BACKGROUND

Across Sub-Saharan Africa, young women who sell sex (YSW) face institutional barriers in accessing sexual health and HIV prevention programs designed for female sex workers. In 2018, Kenya developed a national framework to guide service provision for YSW aged 14-24 years. To help inform the implementation of the framework, we estimated the burden of vulnerabilities related to the Sustainable Development Goals (SDGs related to health and gender equality) and program contact among YSW.

METHODS

We used data from Transitions, a 2015 bio-behavioural cross-sectional survey of 408 YSW aged 14-24 years in Mombasa, Kenya. We estimated the prevalence of sexual (inconsistent condom use), structural (financial, violence), and reproductive health vulnerabilities; and characterized engagement with local HIV programs tailored to sex workers. We then compared the prevalence of vulnerabilities by age group (14-18 years, N = 117; 19-24 years, N = 291) and by program contact (ever contacted by local program for sex workers).

RESULTS

47.3% reported inconsistent condom use with any partner in the previous week (no difference by age-group, p = 1.00). Structural vulnerabilities were common and did not vary by age: 83.6% did not have a regular source of income; 29.9 and 29.2% had experienced physical and sexual violence, respectively. 26.5% reported at least one pregnancy before age 18, and 18.5% used a non-reliable form of contraception with little variability by age. 25.7% were aware of at least one program, and only 13.7% of YSW had ever been contacted by a program (8.5% of those aged 14-18 years; and 15.8% of those aged 19-24 years, p = 0.06). Sexual, structural, and reproductive health vulnerabilities did not vary by program contact.

CONCLUSIONS

SDG-related vulnerabilities begin early in the lives of YSW who are not currently reached by programs designed for female sex workers.

Factors influencing access of HIV and sexual and reproductive health services among adolescent key populations in Kenya

OBJECTIVES

The objective of this study is to identify enablers and barriers in access of HIV and sexual reproductive health (SRH) services among adolescent key populations (KP) in Kenya.

METHODS

A cross-sectional study using qualitative methods was conducted between October 2015 and April 2016. A total of 9 focus group discussions and 18 in-depth interviews were conducted with 108 adolescent KPs in Mombasa, Kisumu and Nairobi Counties of Kenya. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to analysis.

RESULTS

Adolescent KPs preferred to access services in private health due to increased confidentiality, limited stigma and discrimination, access to adequate amount of condoms, friendly and fast-tracked services. Negative health provider attitudes made adolescent KPs dislike accessing health care in public health facilities. There was a lack of adolescent key population's policies and guidelines on HIV and SRH.

CONCLUSIONS

The study has demonstrated existing enablers and barriers to provision of HIV/SRH services for an at-risk population for which limited data exist. The results provide a basis for program redesign involving the adolescent KPs to minimize barriers for access to HIV/SRH services.

HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis

BACKGROUND

HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma.

METHODS

We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation.

FINDINGS

Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1-72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4-57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the least severe legislation (57·4% vs 71·6%, p=0·0056; 35·5% vs 49·3%, p=0·010; 6·7% vs 22·0%, p=0·0050). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5-33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6-71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4-85·5; four estimates), but only 24·7% (18·8-31·2; four estimates) among all MSM living with HIV.

INTERPRETATION

Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90-90-90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM.

FUNDING

US National Institutes of Health, UK Medical Research Council.

Advanced HIV: diagnosis, treatment, and prevention

Substantial progress has been made this century in bringing millions of people living with HIV into care, but progress for early HIV diagnosis has stalled. Individuals first diagnosed with advanced HIV have higher rates of mortality than those diagnosed at an earlier stage even after starting antiretroviral therapy (ART), resulting in substantial costs to health systems. Diagnosis of these individuals is hindered because many patients are asymptomatic, despite being severely immunosuppressed. Baseline CD4 counts and screening for opportunistic infections, such as tuberculosis and cryptococcus, is crucial because of the high mortality associated with these co-infections. Individuals with advanced HIV should have rapid ART initiation (except when found to have symptoms, signs, or a diagnosis of cryptococcal meningitis) and those in treatment failure should switch treatment. Overcoming barriers to testing and adherence through the development of differentiated care models and providing psychosocial support will be key in reaching populations at high risk of presenting with advanced HIV.